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Monday, December 31, 2007

Today we spent with Jonah’s family, trying to give them a breather from mourning, a bit of green grass and sunshine and pizza and coke. Julia the jewel entertained with soccer and Speed Uno, and by the end of the afternoon the bigger girls were at least smiling and the youngest giggling. I realized that we began 2007 with Jonah’s family at his house—a year ago (Jan 1, 2007) we celebrated the 10th anniversary of a previous New Year’s Day feast (Jan 1, 1997) by visiting at their farm for the day, including slaughtering a goat and eating together. That day we thought we were entering a new decade of partnership . . . Today however we brought closure to the grief of this year, and reaffirmed our ongoing friendship and commitment in spite of Jonah’s death. We took a pause in the pizza fest to ultrasound the new baby, who is growing perfectly on schedule for a March 19th arrival . . . and looking rather male (Scott's 95% sure) which made me cry and Melen too, after five girls. We’ll see. Love breaks through and finds a way even in the greatest of losses.

None of my kids want to leave tomorrow for our Team Leader retreat, a meeting scheduled a year ago for Austria, tickets long paid for, and a break we think we need. I understand their longing for home at this moment, and it is not without a good helping of guilt that we will leave for two weeks. The hospital is just beginning to get busier again, and it is hard to leave the staff struggling. But 2008 will begin tomorrow with transience and travel, reminding us that we are sojourners at best, longing for true Home.------------------------------------Post-Script: For those who surf for the sake of the Ebola numbers...

Current Admissions: Bundibugyo Hospital 3 currently admitted; 1 of which was a new admission--there were 5 discharges. Kikyo 1 current admission and 1 one discharged.

The Sunday night numbers while not huge continue to cause concern...
I failed to reach the Task Force Meeting due to mechanical motorcycle problems, but got the report second-hand from a very reliable CDC source...
Current Admissions: Bundibugyo Hospital, 5; of which there were three new admissions. All of the new admissions managed to somehow filter through the Triage System and were admitted to the Bundibuygo Hospital General Wards. After displaying symptoms suggestive of Ebola (high fever, vomiting and diarrhea) each of the three were subsequently transferred to the Isolation Ward. Patients seem to be hiding their symptoms and/or history of contact with cases because of fear of admission to the Isolation Ward. Consequently, more health workers are being inadvertantly exposed to Ebola. This is a huge problem that has eluded a definitive solution.
Kikyo has 2 current cases.
Total Cumulative: 146
Deaths, Cumulative: 36

Saturday, December 29, 2007

In the grand scheme of ebola and eternity, the death of a dog may not seem important, but to the hearts in this home it is the final crushing blow of 2007. Angie was nearly 12 years old, which is a long life for a large dog in the toxic environment of a tropical jungle. Over the last year she had slowed down considerably, but in the last few weeks she could barely walk and finally she was unable to even stand without help. It was time for her to go, but that does not make it much easier.

Angie was Scott’s idea. In 1997 we had three children age 4 and under . . . So adding a dog to the mix was far from my mind. But he saw a notice in one of the first little grocery stores frequented by foreigners in Kampala (for such luxuries as ketchup and mustard) offering a 1 year old mixed yellow lab to a family because the physician owner was finishing her term in Africa and moving back to England. We searched her out and brought her home to Bundibugyo. And never regretted it. Angie stuck with us through war and evacuation. When the ADF attacked us that year and we were running for our lives, Scott took the time to get her on a leash from the line of fire on the front porch and bring her along. She was denied passage on the military helicopter that eventually airlifted our family out, but stayed with Rick Gray in Bundibugyo until we could be reunited. She was never very fond of soldiers after that.

Over the decade she killed her share of snakes and rats, once nabbing a cobra just before Julia walked by it. Our house was never broken into during her tenure, in spite of numerous thefts plaguing other mission houses. When Scott traveled and I was here alone with the kids, I had no fear sleeping at night, knowing she would alarm me to any dangers. In 2001 we brought home another yellow lab puppy, Star. But Angie always remained the top dog, the level-headed one, the trustworthy one.

Her greatest value to all of us was that she represented home. Our kids live as outsiders in an insular culture, slightly out of step no matter where they are in Africa or America, except this little plot of ground. Angie was a force of continuity, unconditional acceptance, faithful love. She was a constant in their lives of tenuous transitions and frequent loss. Whenever we were away, they longed to be back with her, and as we would drive into the yard they would burst out of the doors of the truck to greet their beloved dogs. Her life span fills their conscious memory.

They said goodbye before they went to bed last night, sobbing and stroking. I do worry about the impact of this month on their hearts, this death following so closely upon the frightening separation from us during the worst days of the ebola epidemic. They have seen first hand the groaning of creation, the pain of the Fall (Rom 8). We talked about the New Creation, about Jesus’ words, Behold, I make all things new (Rev 21). We long for that day in a new way this morning, firmly believing that creatures like Angie will be part of that new and good world.

Friday, December 28, 2007

The Ebola Task Force daily briefing was tense and long. The death of a patient who was errantly admitted to the Female Ward of the Bundibugyo Hospital, later recognized as a Ebola supect, later confirmed and then died...after having exposed at least six health workers to the virus--has left the hospital and district anxious and angry.
Current Cases: Bundibugyo Hospital, 5 - of which 3 are new admissions (no discharges, no deaths). Kikyo Health Unit, 4 - of which 1 is a new admission (no discharges, no deaths).
Total Cumulative cases: 143
Total Deaths: 36
Case Fatality Rate: 25.2%
Contacts: 667.
362 finished their 21 day follow-up.
240 visited today.
Please continue to pray for an end to this scourge.
PS Check out this trailer for the 20/20 feature this evening which may include Dr. Jonah (the trailer does!)... the ABCNews 20/20 trailer

I realize how much our souls have been imprinted by the geography of where we live—mid day yesterday Pat and I both experienced such tiredness. I think that in spite of the fact that we are told to get away and take breaks . . . There is a certain amount of tension associated with displacement and transition, and real relaxation comes when we’re back home, back in familiar surroundings with familiar people, back where I know what drawer to open to find a spoon and how to use my stove, which allows a release and a wave of tiredness to wash in. Even though this place is associated with grief and loss, those are only a small aspect of the depth of experience. So it is good to be home, to prepare a meal, to celebrate our family (plus) around our own table together for the first time in over a month, Christmas candles burning, quiet music, all telling our “highs” and “lows” of the day (the former mostly relating to the fact of being home and the thrill of our mountain pass plane ride; the latter mostly related to the illness and decline of our beloved dog Angie).

We came home because we wanted to be here, and wanted to spend a few more days in the fight. But an unexpected side effect has been the confidence boost to the community. I did not anticipate people stopping us and telling us with great sincerity, thank you for coming back, for brining the family, for loving us. I’m glad for that, the simple act of being present translates into the message that we are still part of this place, that we have not given up, that children can still live here too. Public opinion is fickle but we’ll enjoy this little surge of connection and community while it lasts.

This morning I went back to Nyhauka Health Center with Scott Will. We found a half dozen inpatients on most wards (Paeds, maternity, male, and female) and about 30 outpatients. Though many nursing shifts are remaining uncovered there are a core of faithful people at work. We learned that six children have died there this week—of anemia, of waiting too long to come for treatment. The Ebola impact is so much greater than the 36 deaths recorded in the official toll. The fear that keeps people from coming to the hospital, the fear that keeps staff from working, the isolation that impacts our blood bank supply, these things are more difficult to measure. Another child left against medical advice in the night, and will die at home, with signs of meningitis according to the clinical officer. There is no system to track non-hospital deaths, so no way for us to know the true cost of Ebola. The loss of medical staff, the reluctance of those remaining to work, the loss of confidence in the medical care system, these will have an enduring and devastating effect upon the health of Bundibugyo long after the last case of Ebola.

Thursday, December 27, 2007

Yesterday, the delight of anticipation of the end of the epidemic emerged. With only one Ebola patient resident between the two Isolation Wards, the end was in sight.
Today, however, reality crashed in. Bundibugyo Hospital Isolation Ward had two new admissions and the one previous patient died. Kikyo had three new admissions, bringing to five the total number of suspected cases admitted to the two Isolation Wards. The one patient who died proved to be a laboratory confirmed case, the one who had been mistakenly admitted to Female Ward. There is a long list now of health workers who will be monitored for 21 days because of their exposure to that patient.
The total cumulative cases: 139
Total deaths: 36
Case Fatality Rate: 25.9%
Contacts to date: 643
Number who have completed their 21 day follow-up: 330
Number visited today: 235
A new reported statistic being reported: date when the most recent contact will finish their 21 day follow-up and the epidemic will be considered over: ~ January 17th.

ABC 20/20 plans to air a year-end review that will possibly include Dr. Jonah as one of their “Iconic Images” for 2007. The show will air tomorrow, Friday, at 10 pm EST (but different schedules will apply to other areas). We are praying that their take on his story and the images they were able to obtain from our summer intern will bring the story of self-sacrificing love to a wide audience, both as challenge and inspiration. We are not certain yet that he’ll be included, but if he is in the show it will be towards the end.

We are so grateful for the rich experience of family and team immersion for Christmas, from a white dinner under the moon in our rented yard in Kampala to the the fun of surprising each other with simple gifts and resting far from patients and crises. This morning Garrett from MAF treated us to the best ever flight into Bundibugyo, threading through some unexplored Rwenzori folds as we topped the mountain passes and looked down on bamboo and heather, rocks and streams, dropped thousands of feet to float to a stop on the grass airstrip. It was spectacular. Not quite so fun to get home where a dead rat was decomposing by our bed (!) and one of our beloved family dogs is now so old and arthritic she could not rise to greet her devoted fans. On the aistrip Scott met with some CDC people who confirmed that a woman with a miscarriage just before Christmas turned out to be positive for Ebola, and exposed numerous hospital staff by denying her history of fever and exposure to known cases. Sigh. Back to reality. More later today, but all of us are grateful to be back home for a few days.

Sunday, December 23, 2007

Two steps forward, one step backward…the first Ebola death since December 13th.
Cumulative cases: 134
Cumulative deaths: 35 (Case Fatality Rate, CFR = 26.1%)
Case Fatality Rate among Laboratory confirmed cases = 12/34 = 35.3%
Current admissions: Bundibugyo Hospital 5, with no new admissions, no discharges, no deaths. Kikyo 2, with no new admissions or discharges, but one death.
Contacts: 587 of which 148 have finished their 21 day follow-up period. 321 were visited today.
Tomorrow, I will fly out with Pat and three others from MSF to spend Christmas with my wife, my kids, and my Team. As much as I am bursting to see my kids again…I also don’t want to go, to leave behind my fellow soldiers fighting the war against Ebola, against death.
As Jennifer mentions below, our Net access is limited at best in Kampala. Funny, but we are better connected to the world in rural Bundibugyo than in Uganda’s capital.
May your Christmas celebrations be filled with the Life and Light of the World.

Being out of the ebola zone is a respite and a sorrow all at once, a relief to be safe and yet an ache to be away from home, especially for Christmas, especially when leaving behind others who have no respite options. My heart is in Bundibugyo with Scott, yet another part of my heart needed these days to hug my children and absorb the care of living in the community of our team, to weep over Christmas carols and corny Christmas movies, to sleep deeply and eat well. Yesterday most of us attended the Kampala Pentecostal Church’s Christmas Cantata, a 150 person choir, a couple of dozen dancers, a live band, actors, costumes, color, sound, vibrant life and Gospel truth. I sobbed through the first half hour, just the reality of Christmas joy washing over me in spite of the bitter losses of the epidemic, the African life beat of dance and song bringing the familiar story into a new focus. The Spirit is so clearly present at that church, if there was advance seating in Heaven I’d want to be somewhere near the KPC section. Then today we visited a local church, the other side of worship, not the exciting music but the solid rock of truth. The preacher told me after the service that he was a little 10 year old boy who met Jack Miller 30 years ago when he was picking up trash in the Owino market and doing evangelism! Now Gerald is a gifted preacher, and today he looked at Mary’s story. His message: God brings change, His plans are never straightforward and simple, He chooses ordinary people and gives them grace, always calling forth faith, sometimes risky and painful. Mary could have been stoned for adultery . . . But God favored her, chose her, and brought redemption through her flesh and blood. I found that reminder tremendously encouraging as our ideas about our future in Bundibugyo, gradually giving all our work over to Jonah, were clearly not God’s plan. Like Mary, here we are, in an unexpected shelter, with many miles of trials still ahead, and much sorrow already around us, hanging by faith to the character of God, holding on no matter where He takes us.

Tomorrow we will pick up Scott and Pat from the airstrip, the last pre-Christmas act of MAF kindness to fly them out. We will sing and cook and thank God for reunion, open gifts around our little team tree. The list of gracious people who have loved us in concrete ways this month is absolutely amazing. Dan and Gini Herron dropped their lives as Europe field directors in Granada and flew in to shepherd the team through crisis, MAF connected us with a house to rent and the practical details of life in Kampala as well as flying all the responsible organizations in and out of Bundibugyo, our mission’s office staff sent money to treat us to a day off of fun and swimming at a resort, Redeemer Presbyterian in NYC let us know they will fund the Kwejuna Project food for pregnant HIV positive women for the next year, 50 people have bought goats, over ten thousand dollars (with pledges up to 20) has come into the Africa Response Fund (goal 100K), people whom we’ve never met send us encouraging words. I’m not sure I’ll be able to post for the next few days, so let me close with a deep note of thanks, and a wish for a fresh encounter with the living God this Christmas, be it merry or crushing, I pray that we would all cling to Him.

Saturday, December 22, 2007

- Cumulative cases: 134- Cumulative deaths: 34- Current admissions: Bundibugyo Hospital 3, with one new admission and one discharge. Kikyo 3 with one admission and no discharge. No deaths in either ward.- Contacts: 584 cumulative, with 125 finished their 21 day follow-up and 379 visited today.

Issues discussed in the Task Force Meeting…

Most significant and distressing. A woman presented to the outpatient department of Bundibugyo Hospital yesterday with symptoms consistent with a miscarriage (vaginal bleeding after a period of amenorrhea). Because of her bleeding she was questioned about the presence of other symptoms related to Ebola (and any history of contacts). She denied such. She was admitted to the Female Ward as a run-of-the-mill spontaneous abortion. A few hours later she developed bloody vomiting with nose bleeding. She was promptly transferred to the Isolation Ward where she is being handled as a suspected Ebola case.

As you might guess, the hospital staff has been thrown into a “fresh panic”, and rightly so. The triage system failed, possibly due to misrepresentation or deceit on the part of the patient in an effort to avoid admission to the Isolation Ward or possibly due to an error in judgment on the part of the triage staff. Hard to say with my limited information. Triage protocols are being reviewed and the staff is being counseled. The situation reemphasizes the reality of the risk of accidental Ebola exposure to general health workers in Bundibugyo. Those NASA-like space suits completely protect health workers from Ebola virus in the Isolation Wards who are knowingly exposing themselves to Ebola, but we can’t live our lives wearing those suits. Sadly, this dark cloud of doubt will probably linger in the minds of Bundibugyo health workers for months (or years) to come. Whenever a patient presents with fever and vomiting, nurses and doctors will wonder if Ebola is possibility. It’s frightening.

On a brighter note, the biggest Bundibugyo market of the year, the Nyahuka Saturday-before-Christmas Market occurred today. A frenetic rush to procure new clothes, shoes, sodas, and other party provisions (goats, chickens, and palm oil…egg nog and ice are not on the list). Excitement (and perhaps are bit of desperation) seemed to be the prevailing emotion of the day…rather than fear…and for that I am very thankful.

Friday, December 21, 2007

Today's numbers...-Cumulative cases: 132-Cumulative deaths: 34 (CFR 25.8%)-Current Admissions: Bundibugyo Hospital 3, of which 1 is a new admission, no discharges and no deaths. Kikyo Health Unit has 2 inpatients, with no new admissions, 1 discharge and no deaths.-Contacts: 577 total, 124 completed their 21 day follow-up, and 379 (94%) were followed up today.

Issues of the evening briefing (see the picture of the Task Force meeting above):- 5 dogs were found dead in Bundibugyo Township today causing general panic due to fear that the dog deaths could be caused by Ebola. CDC experts assured everyone that Ebola has never been known to be found in dogs (collective sigh of relief).-70 herbalists were sensitized/trained today. Not sure exactly what that means or how effective the training will be.

Thursday, December 20, 2007

A small milestone. The last death occurred one week ago, 13th December. The beauty of the line graph above is the flattening of that slope on the right. A whole week without an Ebola death...that's a cause for celebration.

Today's numbers:-Cumulative cases: 131-Cumulative deaths: 34 (CFR=25.9%)-Current admissions: Bundibugyo Hospital 2, with 1 new admission, no discharges and no deaths. Kikyo Health Unit has 4 inpatients, with no new admissions, 1 discharge and no deaths.Contacts: 571 of which 432 are being followed-up. 94 have completed their 21 day incubation count-down. 89% of contacts were seen today.

Issues discussed in the evening briefing:-World Food Programme will be giving a generous package to the families of all Ebola patients: 75 kg of corn meal, 11 kg of dry peas, 3.7 kg (one can) of vegetable oil, 14 kg of corn-soya blend, and 3 kg of sugar.- The Batwa (a.k.a., the pygmies) have appealed to the LC5 Chairman because they are "bad off" because of Ebola. They claim that they depend on the income generated from tourists who have stopped coming to Bundibugyo because of Ebola and that they are starving. In fact, the Queen Pygmy has deserted her husband, the King, because he is not providing for her. Abdicating the throne because of hunger...things are bad in Bundibugyo. The Task Force requested that their request be redirected to other donors so as not to confuse our mandate which is to treat and prevent Ebola infection.-The Democratic Republic of Congo has closed the border to incoming traffic. Congolese citizens may enter Uganda freely, but not re-enter the DRC. Congolese nationals who want to re-enter their country from Uganda are being admitted to Isolation Tents whether they are sick or not. Unnecesary, extreme, mis-informed.

Jonah's wife, Melen, and her family returned from their outlying farm to their small concrete home in Nyahuka last night. Melen, Sofia and Jonah's mother wept all evening. Pat slept with them and read Scripture to them all morning until the stream of visitors began which lasted all day.

Wednesday, December 19, 2007

One of the World Health Organization experts told us that in the best case scenario we would see the number of cases cut in half each week. The admitted caseload peaked at 40 about 2 weeks ago, so with the current admissions numbering 6, things are looking pretty good.

Today's numbers:- Cumulative cases: 130- Cumulative deaths: 34 (CFR = 26.2%)- Current admissions: Bundibugyo Hospital 1, with no new admissions, 3 discharged, and no deaths. Kikyo has 5 current, with 2 new cases (both identified from the pool of contacts who are being visited daily), 1 discharge and no deaths.-Contacts: 571 total of which 450 are being actively followed (77 have finished their 21 day incubation monitoring and the remainder were lost to follow-up). 86.4% of the contacts were visited today.-Lab confirmations: of the 108 samples sent for testing in the CDC/UVRI lab in Entebbe, 32 have been positive (29.6%). Of the 32 positive samples, 11 died (CFR = ~34%, slightly higher than the overall clinical CFR mentioned above)...probably closer to the "true" CFR of the Ebola-Bundibugyo strain (Btw, still waiting on that name to be officialized).

The District Task Force meeting continues to chase administrative details rather than medical or epidemiological questions. Today's issues related to the number of individuals of a village health team who could receive renumeration for assisting the surveillance teams and who would distribute food donated by the World Food Programme. Every confirmed Ebola case will receive a month's worth of food for a family of six.

My favorite anecdote of the meeting came out in the Surveillance Committee report. When a patient is discharged from either of the two MSF Isolation Units, they are asked to surrender all of their properties for incineration. Their mattress, their clothes, their toiletries...up in smoke -- along with any residual virus. Well, one patient was asked to surrender his cell phone (any studies out there on the duration of Ebola virus viability in a cell phone?)...which he relinquished without complaint. However, he did follow-up over the next couple of days with a couple of calls...and found that his phone is still in use! The surveillance committee is pointing the finger at the Isolation Ward staff for poaching the infected cell phone.

"Burn it or give it back," the patient has asked (he's not afraid...he's immune now).

Tuesday, December 18, 2007

Dueling posts? Jennifer has posted this evening from Kampala because she flew out of Bundibugyo with MAF this afternoon to re-join our kids, capitalizing on her first opportunity in 14 years to sit in the co-pilot's seat. Flight protocol states the plane must be loaded heaviest in front, so Jennifer has always been relegated to the rear with the small kids. As the only passenger on today's return leg to Kampala, she had no competition for the premium seat.

This evening's District Ebola Task Force Meeting revealed a continuing tapering of the epidemic...

- Cumulative Cases: 128- Cumulative Deaths: 34 (CFR = 26.6%)- Current Admissions: Bundibugyo Hospital 4 ; with no new admissions, 1 discharge, and no deaths. Kikyo also with 4 inpatients; 2 new admissions, 3 discharges and no deaths. Of the 8 currently admitted to the Isolation Wards, they hope that 6 might be discharged tomorrow.- Contacts: 535 have been listed with 426 actively followed (the remainder finished their 21 day waiting period--the Jonah family will hit their 21 day goal tomorrow). 85.2% of the contact list were visited today, a huge and punishing task in the unrelenting sunshine today.

The most intense discussion of the evening again revolved around the issue of "traditional healers" , also known as "herbalists", "traditional herbalists", "alternative practitioners","witch doctors" or "jujus". The lines between these practitioners seem indistinct, and in fact, they appear to jump back and forth between the roles depending on circumstances. Hundreds of these healers prescribe their concoctions of locally gathered substances (77 different tree sources) in drinkable teas, smearable pastes, or otherwise unspeakably applied mixtures for all sorts of common illnesses...and now they are taking credit for the successful treatment of Ebola patients.

Where does the Task Force draw the line between challenging engagement versus tacit endorsement? Clearly, this group is out in the community on the front line of caring for people with illness and cannot be ignored. However, their practices and pharmaceuticals have not been scientifically studied and cannot be endorsed. They commonly make small incisions to "let bad blood out" and to promote the absorption of their smeared herbs, a practice that could put them at extremely high risk of contracting Ebola themselves or promoting the transmission of the virus to others. Thankfully, reason prevailed and the Task Force unanimously agreed today that this group should be strongly discouraged from treating any Ebola patients. Whether they can be convinced is an entirely different question.

I flew to Kampala today, and am now with my four children after two weeks and one day of separation. Thanks to the many who prayed. Now Scott will be updating the blog from Bundibugyo. It was amazing to fly out over the epicenter today, seeing the white MSF isolation tents like mushrooms sprouting around the Kikyo health center. Smoke rose from forest-clearing fires, the ridges shone with the diamond glitter of tin roofs reflecting the afternoon sun, and the line of the forest where the elusive viral reservoir hides was clearly visible. All so orderly and peaceful from the air . . .

Monday, December 17, 2007

Today we are celebrating emerging from the danger zone, though the joy is heavily mingled with the deep sadness of those who lost their lives, particularly Jonah. In the dark hours after his death we truly thought we might not be writing this today. So we should thank God that for His inscrutable reasons He has ordained that we remain symptom free for 21 days, and in the clear. Melen and family reach their safety zone on Wednesday. In our daily visits I sense a slight lightening of spirit, a hope.

Tonight’s meeting saw the RDC, the LC5, the DDHS, and the CAO (chief administrative officer), the four most powerful men in the district, all back in place. The RDC opened with the statement that the enemy has just made a tactical withdrawal but is not defeated, so don’t relax. The struggle continues.

Cumulative cases: 126

Cumulative deaths: 34 (holding for DAYS now); CFR 27%

Current Admissions: Bundibugyo 5; with 2 new admissions, 1 discharge, and 0 deaths. Kikyo also 5, with 1 new admission, 4 discharges, and 0 deaths. More discharges expected tomorrow.

Contacts: 487 have been listed, with 408 being actively followed (others like us have reached the 21 day limit). Today 88% of those were evaluated by energetic mobile teams, now boosted by five young MPH students from the Institute of Public Health, all Ugandan doctors who have joined the CDC in their efforts.

Complaints: tribalism surfaces again, with the Bakonjo claiming that the social mobilization teams are speaking only in Lubwisi . . . Which prompted a LONG discussion of the mobilization effort. Are the Bakonjo areas just harder to reach (steep, scattered), or are the complainers angling for jobs and pay, or is there really any problem at all? Much emphasis was put tonight on using the LC1 system, the political organization of the country, to address communities. I think they ended up deciding that various big men should volunteer to train LC1 chairmen to reach every community.

Dissension: much discussion again of local herbal remedies, with some herbalists now spreading the word that certain recovered cases only recovered due to their medicines . . . And not so surprisingly, many of the people in the task force are not so sure, the power of the belief in traditional medicine is widespread. A couple of brave voices asked for science to interpret the results, and warned that if herbalists are invited to participate as part of the official task force then we will be inadvertently authenticating their claims.

Money: there is now a 2 billion shilling plus budget, but the Ministry has to approve it. Refreshing moment: In contrast to all the grabbing we see in the political sphere, we were handed a document today by one of the translators who works on the Lubwisi Bible project, who had taken the information about Ebola and translated it. Unlike everyone else we have encountered, this man wrote at the bottom: translated at no cost, for the good of the people of Bundibugyo and the glory of God. Amen.

And the emotions of the day for us: relief, and eager anticipation of going to Kampala tomorrow (Jennifer) to see the kids. At this point we are still planning that the non-medical team stay out, and Scotts and Pat join the rest for Christmas. But our kids call several times a day asking when they can come home, and why not for Christmas. Now that the epidemic has slowed in its relentlessness, we are torn. We don’t want anyone to be exposed. But the chances of that are remote for those who don’t see sick patients. Our kids’ friends, who are flocking back to our house, asked today, when are they coming, and why not now if you are safe? Once again, we are torn by our care for these kids, and the painful reality that our standards for our kids and team are different than our standards for local people. Unfair, and stressful when you’re here facing reality. Actually most of the rest of the country and the world is probably more uptight about Ebola than the average person in Bundibugyo, and for good reason. If you aren’t here, then Bundiubugyo = Ebola. If you are here, then you see that 99% of life is about other things, the normal human interactions that constitute a day. Pray for wisdom for us and our mission leadership, who have to buy into the decision on when to sound the all clear.

And tonight, to close, a little reminder of life going on. Dear team mate and friend Heather Pike Agnello is in labor with her first baby, while a few hours from now dear team mate and friend Rick Gray will celebrate the milestone of 50 years (Dec 18!!!). Happy birthdays.

Fellow WHM colleagues in Ireland passed on this poem to us.
A poignant image of death as merely transition...
I am standing on the sea shore,A ship sails in the morning breeze and starts for the ocean.She is an object of beauty and I stand watching herTill at last she fades on the horizon and someone at my side says:"She is gone."Gone! Where?Gone from my sight, that is all.She is just as large in the masts, hull and spars as she was when I saw herAnd just as able to bear her load of living freight to its destination.The diminished size and total loss of sight is in me,not in her.And just at the moment when someone at my side says,"She is gone", There are others who are watching her coming, and other voices take up a glad shout:"There she comes"- and that is dying. An horizon and just the limit of our sight.Lift us up, Oh Lord, that we may see further.Bishop Brent1862 - 1926

Sunday, December 16, 2007

Today, the non-medical side of Ebola . . . Or the real-life, long-term side of it perhaps. After Scott did his very public thanks and contact-greeting with survivor Fred, Pat gave him a Bible, and he came to our house for a coke and sandwich. Meanwhile a reporter for a Christian Dutch news service who had traveled to Bundibugyo showed up at church too, so he took advantage of the time to do interviews with the nurse, then with Scott, and briefly with me. He lives in Kampala but earns a living by writing stories and radio shows for the Netherlands. He was just leaving when the CDC team came, we had invited our fellow-Americans to cheer and encourage them with pizza and a break from the front lines. It was one of the hidden blessings of the outbreak, to enjoy the company of these young doctors, swap stories, and send them back into the battle a little fortified. Also the evening briefing is a bit more palatable after a good meal . . .
The medical side continues to improve:

Cumulative Cases: 123

Cumulative Deaths: 34 (stable number once again); CFR 27.6%

Laboratory: no news, no planes on Sunday, so no new samples analyzed.

Contacts: reporting was a bit more fuzzy, the teams are definitely out there tracing, there is a concerted effort to add contacts of new cases to the list. The surveillance team seems to find questionable people on a daily basis who have some sort of symptom, but rarely get admitted, so then aren’t counted as cases. There seems to be a gap between contact tracing and case identification, hard to tell from the briefing but we might be missing some people, or focusing attention on people who aren’t real contacts, because the stakes are high. Either mistake is potentially costly, to leave infectious cases in the community, or to distract resources towards non-Ebola sick people.

Admitted to Kikyo Isolation Unit: 8. 1 new admission (was a support staff who worked in isolation, so yet another health care worker contact falls ill), 1 discharge, 0 deaths. There was also a readmission of a previous Ebola case but he is a man with chronic hypertension, so his readmission was judged to be due to this chronic problem and not to Ebola.

Politics: The entire two weeks we’ve discussed the lack of a vehicle for Kikyo to serve as an ambulance. They are supposed to have two separate trucks, one to bring patients in (ambulance) and one to go out and bury the dead. Every day the hard-working staff complains about the lack of a vehicle. Every day there is a different person to blame. It is broken, it is in the shop, the district hasn’t paid the bill, the fuel wasn’t available, it is back in the repair shop . . .and today’s explanation: the driver could not be found. It seems that drivers signed up for the extra allowance of being Ebola-response team members, but none actually want to go anywhere with Ebola, so Kikyo is not a preferred route. WHO suggested that drivers only be paid AFTER driving. Sounds good to me too.

Cultural issues: a doctor from Kampala warned that Christmas might be a risky time because the local people would want meat and therefore poach wild animals from the forest, accelerating the epidemic. While isolated cases of this hunting probably did trigger the initial transfer of the virus from the supposed animal reservoir to humans, the entire district certainly doesn’t go poaching for Christmas. I guess I’ve lived here long enough that I felt personally offended by the underlying cultural superiority of the comment, people from other parts of Uganda look down on Bundibugyo people as primitive. I wanted to raise my hand but had already been attacked for a previous question, so I waited and was actually quite happy when our own DDHS very politely explained that as the senior indigenous person present, he wanted them to know that this is a season for cocoa, and the local people get money for their cocoa and use it to buy beef, goat, pork for Christmas, they do not go poaching from the parks. There was also a suggestion that circumcisions be deferred until after the epidemic. This was agreed to be a wise move. Usually Dec/Jan is the main season for circumcisions, boys are off school and can go through their initiation in groups. Some years seem to be more popular than others. Any procedure that involves blood and is not urgent should be delayed. So next year might be a better choice.

Today’s sermon was on Elizabeth and Zachariah, on God bringing joy into a situation of barreness. We so easily criticize Zachariah for his lack of faith, but I sympathize with him this year. This is a bleak season for health and the Kingdom in Bundibugyo. To see God’s work here takes faith, and I’m sure I’d be tempted to point out the facts to an angel. Praying for hope, for the nine-month view ahead to what God will do.

Today Scott stood up to introduce Fred Lubwasa in church—Fred is a UPDF soldier and nurse who volunteered to work in the isolation unit back when we didn’t understand the epidemic, then stayed on when he knew it was Ebola. We first met him three weeks ago, the first time we were examining patients there. His exposure led to infection, and he battled for his life. Now discharged, he thanked Scott for the prayers of the people, so Scott invited him to church. As they stood together, Scott put his arm around him and shook his hand to show that post-Ebola patients are not infectious and should not be ostracized. He pointed out that God looks at the heart and in God’s kingdom this nurse is a “Big Man.”

We are also posting some additional pictures today of the other Heroes of Ebola.

Rosa Crestani, the MSF Medical Coordinator who led the advance team, moving in to create order in the chaos, passionately caring, with that core of steel that allows her to do her job even when criticized by politicians (and she’s had plenty of that in the meetings!).

Dr. Yoti Zabulon, the energetic and patient young doctor, who survived the Gulu Ebola epidemic of the year 2000 and then pursued a career in Infectious Diseases with the WHO in Uganda, flying to every trouble zone in the country to offer service, leadership, and wisdom.

Our Resident District Commissioner Sam Kazinga, who represents the President's Office to the District, with his commanding presence and insistence on work, pulling all the agencies together and keeping the Ebola District Task Force focused on their task, dispelling rumor and insisting on excellence.

Monday Julius, the Clinical Officer In-Charge at Kikyo Health Unit, who has been caring for Ebola patients at the epicenter since it began, seeing more Ebola patients than any other person in the district...and who has managed not to get sick with the disease!

And there are many others, the fresh faces from CDC who track contacts and draw blood samples and diagram transmission chains. The voices of experience from WHO and elsewhere who have seen this all before and know what to do next. The doctors from Ministry of Health who left their homes and families behind to shore up the devastated medical system here. The committed and competent field workers from the Red Cross who scour the district for contacts and cases.

Dr. Ian Clarke writes a weekly column, and in today’s he praises two doctors in Kampala working with paediatric AIDS. In that same spirit we applaud the heroes we’ve seen here. Just when one is tempted to despair over Uganda, these people remind us that God has his people everywhere, fighting the good fight, showing mercy, using their talents to serve others.

Contacts: 423 identified, 327 being followed, 286 seen today (87%). 42 people moved off the list at the end of their 21 days.

Surgeries Scott performed today: 3. He was called this morning by the police surgeon from Fort Portal who said he needed to go home for the weekend, so could Scott be on call. . And a few minutes later the first emergency C-section call came. So Scott and Scott spent the whole day at Bundibugyo hospital, once again the only people seeing non-Ebola patients. This pinch-hitting is very stretching for them, dealing with cases that come very late and very sick . . . Thankfully a healthy baby boy was delivered by C section, an 18 year old bleeding excessively from a miscarriage had a d and c, and another lady’s life was saved when she came with a retained placenta. Before and after all that Scott was dealing with airstrip maintenance. It’s a lot of work to be here these days.

Best comment of the day: Dr. Sessanga’s son. It is a privilege to be a source of information even for Ebola patients’ family members in Uganda, to encourage prayer and hope. A small way in which this crisis bridges cultural barriers and connects us all.

Friday, December 14, 2007

Two weeks and one day since the diagnosis of Ebola was made public. Two weeks since the MSF preparation team came, 12 days since the first real medical staff, and 10 days since the overall organized response took shape. In that time it is good to think about what has NOT happened. Ebola has NOT been confirmed anywhere outside of Bundibugyo. Hundreds of new cases have NOT materialized. Health centers in addition to the two primary foci have NOT been swamped with cases. It has been a stressful and uncertain two weeks, and a time of great loss and sorrow. There were many points at which it seemed we might be reaching the potential beginning of the end of life as we know it, with diffuse spread of the infection and overwhelming fatalities. Thankfully that has not happened, but now the weariness of grief is beginning to catch up with us, the change in pace to the long-haul. And with that shift comes the district and ministry wrangling over money, power, and control. Scott spoke up in tonight’s meeting on behalf of compensation for health workers who were infected and recovered, as well as the families of those who died, concerned that these people were getting lost in the scramble for the money flowing in. He was immediately attacked by at least three people who sensed a threat or challenge to the proposal of huge allowances for all numbers of people, some of whom are quite peripherally involved. Sigh. I think it is a small reflection of the kind of pressure Jonah faced. If we aren’t a threat to the way things are, we shouldn’t be here. And so it goes.

Confirmed cases by lab: 32 still, but now we got the information that 11 have died, 7 are still admitted, and 14 have recovered. If those 11 are the only ones to die then the CFR among laboratory confirmed cases will be slightly higher than the overall, at 34%. The numbers are small, and this CFR could be falsely lowered by the fact that the sickest patients did not survive to get their labs drawn, or falsely elevated if we go back and test lots of people for antibodies since we’ll only find the survivors. Still it is the best number we have, and would suggest this strain is less lethal than other strains of Ebola.

Contacts: 345 (17 were removed from the list for reaching their 21 day limit, a milestone we look forward to next week!). Over 90% were followed up today.

Interesting stories: the two biggest clusters of related cases have been mapped out. There do not appear to be multiple sources of this infection crossing from the supposed animal reservoir to humans. This is excellent news, since it was certainly possible that Bundibugyo might have had lots of little mini-epidemics all cropping up in this time period. Most cases seem to be directly related to each other. However not all are testing positive, which may mean that we are looking at not just another strain of Ebola but something else as well. We continue to be thankful for the excellent and inquisitive minds who are focusing their energies on this.

Sad news: there was a massive turn over in staff today, especially WHO, including three of the men whom we have grown to really trust and respect over the last ten days. They will be missed. Dr. Yoti promised to come back. Other sad news was that a mission house was broken into, the thieves dragging a safe a long distance and then sledgehammering it to pieces. They were probably disappointed to find it was pretty much empty. Sad for all of us that people would use this time to take advantage of others.

Happy news: The UPDF nurse Fred, whom we met in the Bundibugyo isolation unit the first time we went to investigate patients, recovered.

Some men that Scott lived with in college, 25 years ago, let us know that they are coming together to pray for us. A dear friend whom I have known since I was born, and almost never had an email from, wrote today. We continue to be humbled by the outpouring of love and concern from the amazing network of friends God has blessed us with. We even had a call today from the National Forestry Authority official who nearly arrested us last Christmas when we cut down a pine tree (with permission, but it turned out that the permission was not from the people who had authority to give it . . . ). He wanted to be sure we are OK, and asked us if we had our Christmas tree yet for this year! For the first time in my memory I have not done any preparations for Christmas at all beyond packing a hurried trunk of things for my children when we sent them off. But the team in Kampala had tree and decoration plans for tonight, so we politely declined the NFA friend, though we appreciated the thought!

Thursday, December 13, 2007

Contacts: 368, with 264 seen today (71.7%) This is the heart of containment, having surveillance teams face to face daily with contacts to monitor any who become ill, and encourage them to come in for isolation and care.

Admitted in Kikyo: 9, with 0 new admissions, 0 discharges, and 1 death. We learned today that two of these are women who are breast feeding babies (age 3-4 months), and since the virus is highly transmissible in breast milk we are providing formula tomorrow so that the babies can be watched in isolation for symptoms but separated from their mothers . . . Another sinister aspect of this disease and the way it insinuates into the very relationships that should bring comfort and support.

Stories: well, there were a couple of sad ones. First, a pastor died, a man who had prayed for Ebola patients before we knew it was Ebola. In my view it is just like the health workers dying. This man laid down his life by caring for others. He probably laid his hands on Jeremiah Muhindo as he prayed for him. So did Scott. That always sobers us, though each day we move further and further from the common incubation period, and closer to the 21 day safety zone. The clinical officer Joshua Kule’s son is another problem story—it came out in the meeting that a surveillance team visited him and determined that the fever he had was improving on antimalarials so he did not have Ebola. At that point our MSF nurse spoke with obvious conviction and care: it is DANGEROUS, she said, for the surveillance team to think they can make that judgment. Any contact with fever has to be evaluated by a medical person and tested!!!! This man was the primary caretaker for his father, who died, and is exactly in the incubation period for symptoms. Cases like this make it clear that we are not yet out of the woods. Because people fear the isolation ward, they will try to hide or minimize symptoms, and thereby put their families and communities at risk.

High of the day: Scott was able to visit four of the five families of health workers who died, taking them some food and comfort and words of Scripture about God’s care for the orphan and widow. I think it was a touch of kindness and contact in a disease that is otherwise frightening and isolating. And a way to show extra respect for the lives of these men and women. He also tracked down the children of a woman admitted now, who is not dead, but whose children have been reported to be fending for themselves.

Low of the day: Well, several really. One is that the voices of reason and wisdom and experience may be thinning out as we end our second week of crisis response. We hear rumblings that the CDC team is narrowing down to one (a really nice guy, but still only one of him) and our trusted WHO doctors and epidemiologists are also hinting they won’t stay much longer. An experienced person warned us today to expect things to temporarily deteriorate again between Christmas and New Year as people slack off .. . Which makes us feel like we should be here then. I miss my kids a lot tonight, more than usual, maybe hearing about them first-hand from Pat. It was a discouraging meeting tonight, focused on money, and while I respect the hard work and leadership of most people involved, I feel the cross-cultural tension of distaste for the fact that the biggest budget items are extra allowances for most of the politicians. My American viewpoint is that they are doing their job, so why should UNICEF money go to their pocket? But I know the African view would be that they are underpaid, and that they are putting in extra hours, and that it is only right that their work be valued in this way. But I have to confess it still grates on me.

Unlikely heroes: MAF. Mission Aviation Fellowship flies people in and out almost daily, ferries blood samples to the lab, brings supplies here. They also have found our team a house to stay in in Kampala, and helped them with everything from a generator to groceries. We are a small mission, and in many ways MAF functions as our support base. The pilot today even took an extra hour on the ground just to visit us and pray for us. We are so grateful.

I’m wearing a shirt tonight in honor of Pat returning, a shirt that she gave me after buying it right off the back of a man in the market who was wearing it, during the ADF years. It says: If you aren’t living on the edge, you’re taking up too much room. Here we are on the edge, hanging on.

Dr. Steven Sessanga, the Medical Superintendent of Bundibugyo Hospital, was formally discharged as an Ebola survivor yesterday. President of Uganda, Yoweri Museveni, called him on the phone yesterday to congratulate him on his recovery. His illness lasted for nearly two weeks. His exposure occurred during his care for Mr. Muhindo Jeremiah, the same patient from which Dr. Jonah contracted the Ebola virus.

Issac, a nursing assistant at the Kikyo Health Unit also recovered from a prolonged illness due to Ebola infection. His severe vomiting and diarrhea resulted in his need for 61 bottles of IV fluid. He's currently back on the job, effectively immunized and safe from any infection from the Ebola-Bundibugyo strain (the title of the strain has not yet been determined).

District officials would like to capitalize on the fact that some patients--even health workers--are surviving Ebola. There's a tremendous resistance to admission to either Isolation Ward, as it is perceived as a death sentence. The experience of these two heroes challenges that fear.

Wednesday, December 12, 2007

We flew home at dusk on Scott’s motorcycle, the sky pinking westward and mist shrouded mountains silhouetted eastward. I saw a young girl dancing with abandon as we passed, and many people greeting, talking, walking, carrying their burdens and cooking their food, smoke rising from fires, just like any other day. Yes, Ebola is here, but for the vast majority of people it is only a shadowy fear, and their real life continues. I lose sight of that sometimes. A week ago we were stumbling through our tears and anticipating illness, wondering if we would leave this place alive, and if we did could we ever come back? Now a week later hope surfaces again. Even Melen is smiling more readily, her shorn head a final sign of her mourning coming to completion. This place breaks my heart and demands my all. But in God’s economy, that draws out love. I have thought often this week that the pain which was introduced into childbirth by the Fall had a redemptive consequence: that for which we labor with such cost becomes dear to our hearts. In the paradox of the Kingdom, a difficult child becomes the one that we love. And a place so steeped in death becomes a place that we deeply care for.
Today’s numbers also carry seeds of hope:

Cumulative cases remain at 115. There was a story of a contact with fever who had not been reeled in quite yet, so it will likely increase tomorrow, but for tonight we’re stable.

LABS: still in process, but there have been 31 confirmed positive samples, all from Bundibugyo district. All samples from suspected cases in other districts have proven negative to date.

Spread: As above, all Bundibugyo so far, but Bundibugyo contacts have been dispersing themselves. They want to get away from Kikyo, away from the disease, and have been turning up in neighboring districts. So it is very possible that true cases will arise elsewhere.

Contacts: 265 of 368 followed up today. Jonah’s family has six more days to make it to 21 and all are well. I have five more.

Issues: there was a call for projections in order to plan the budget. Will this go on for a month? Two? More? The epidemiologists are supposed to bring us their best guess tomorrow. I did talk to the CDC and MSF about the impact on resuming Christ School. The official policy from the outsiders is that contacts should be able to continue their normal activities until they have a fever. They are not supposed to be very infectious the first day of illness, which gives time for isolation. I do wonder if the teachers or students will be willing to return even if we give the medical all clear. Anyway this should be more clear by early January when we’ll know the trend of cases better. Half the time I feel like life will go back to normal; half the time I feel like the stress of evaluating every fever or whiff of illness in everyone we know as a potentially fatal disease will be unbelievably stressful.

Medical Care in General: Scott and Scott worked at NHC today. Scott W saw all the HIV positive people and even saved a child’s life by putting in a more complicated IV line for a blood transfusion. Every day that we don’t have Ebola cases at Nyahuka makes us more comfortable with expanding services there once again. We wish we had better mortality data for the district in general. I spoke with a family today whose baby had died the day after the Ebola announcement. I’m sure there are many dying at home, of malaria and anemia and sepsis and everything else, afraid to come for care.

Luke should have landed by now, we’re waiting for his call. Pat plans to drive back in tomorrow.
See the posts below for a Christmas meditation, and the reminder of links for donating to help Jonah’s family and other needs. Scott will take food tomorrow to two widows (Joshua Kule’s , the clinical officer, and Anansio Maate’s, the eye assistant, as well as two children whose mother is in the isolation unit, and visiting to check on Melen, one of the ways we as a smaller organization can fill some gaps).

A week before the news of Ebola broke, we sent our annual Christmas letter to WHM for mailing. It was written from our hearts, and looking back we can see that God was at work to draw us into the struggle with the whole theme of collateral damage in the story of His coming.

If you would like to read it, click on the "downloadable prayer letter" link on the right side bar to get the pdf file.

Tuesday, December 11, 2007

Reading Job this morning, and that’s what the book is about. Job’s friends try to put God in a box. If you do A, God will reward you with B. It is only in grief, tragedy, lament that real worship begins, not grasping God for His gifts but clinging to reality in the midst of confusion. God does not answer with formulas but with poetry, not with explanations but with presence. Today the churches will be praying and fasting for the end of the epidemic. We ask for that. But we don’t pretend that if there is enough outcry, then surely God will act the way we want. No, we pray to say that we have not given up, that we still seek God’s presence in the face of loss.

First, let us thank our Minister of Defense Dr. Crispus Kiyonga, who wrote a tribute to Dr. Jonah in today’s New Vision. Dr. Kiyonga was at one time the Minister of Health, and we met him when we were both “mature” students at Hopkins. In fact his picture was on our blog last month when he stopped by to greet us. He has been concerned and calling many of us over the last few days, and today’s article is a very moving tribute to health workers here. We very much appreciate it. Here is the link: http://www.newvision.co.ug/D/8/459/601388

Second, we continue to get calls from the erroneous radio report today that Scott is sick with Ebola. It is a rare opportunity to experience Mark Twain’s famous quote: rumors of my death have been greatly exaggerated. Though we can take it with a dose of humor, we do feel terrible for our friends who live in fear and have lost so much already, to have to hear another report of bad news.

Now the news:

Total cases remain at 115, the first time we’ve had no new cases or admissions. Praise God for a respite.

Deaths: 31. CFR 26.9%. One of the deaths today was the 20-something daughter of Jeremiah Muhindo. She had been fairly stable, and we had hoped she would pull through. It is an example of the power of this virus that even healthy young people who initially seem to have great hope sometimes succumb.

Census: 16 Bundibugyo, with 1 discharge (Dr. Sessanga), 1 death, and no admissions. `12 in Kikyo, with 1 death and 1 readmission.

LABS: no new results.

Spread: four highly suspicious cases in Fort Portal, all are contacts from Bundibugyo. We agree with the advice that contacts should stay put for 21 days to help contain the spread of this disease, and we are doing so ourselves. So far Jonah’s family is fine, again a tribute to his care.

Contacts: 359 identified, 152 followed up today.

Can life become any more bizarre? We ask that frequently. Our dear elderly neighbor has been struggling with congestive heart failure, hypertension, a hip fracture, and possibly cancer . . . So when his son came to call Scott to see him urgently today, I ran over to assess the situation. Twice in the last year he has been near death but sustained by good management of his medications when Scott adjusts them . . .I found everyone on the porch and our neighbor in a closed room alone. He had urinated blood colored urine. The family was panicking. He had no fever, no vomiting, no diarrhea, no contact with Ebola, so I reassured them that this was most likely a urinary tract infection, common in bedridden older people. But what are the chances that such a sign would come up precisely in the middle of an Ebola epidemic???

Last but not least, Luke is boarding an airplane in the next few hours, to return home. His grandmother will miss him terribly; his siblings are going to be bolstered by his return. I will see them as soon as my 21 days are up. Pray for safe travel.

The roller coaster continues to rise and plunge, from hour to hour. One day we wonder if the world as we know it is ending in an ever escalating toll of death, the next day we realize that some people are recovering and feel hopeful about putting this tragedy behind us. A BBC (Network Africa show) reporter interviewed Scott at 7 am this morning, and he was able to speak sincerely about our loss of our friend Jonah . . . We wanted to honor him. But then this afternoon Bamparana, Ndyezika, and Byarufu all rushed to our house, having just heard on VOT (Voice of Toro Fort Portal radio) that Scott had Ebola, a misinterpretation of comments regarding Scott's history of contact with Ebola patients made in the BBC interview. They were reassured to see him fine, and we were reassured to know that at least a few people are out there who would come and check on us . . . And so it goes, up and down.
Today’s big event was the visit of the Minister of Health, the Honorable Dr. Stephen Mallinga, along with the Commissioner of Community Health Services, Sam Okware. We were steering clear of the hooplah by running a training for NHC staff but the RDC and the temporary medical superintendent from MOH stopped Scott on his way back from discharging Dr. Sessanga (cured!!) this morning and told him that they had assigned the training to one of their own doctors, instead he should come greet the minister. He turned back to Bundibugyo, and Scott Will and I went to Nyahuka to meet with about 40 staff, along with a doctor finishing his Masters in Epidemiology at Makerere and a senior nurse who survived the 2000 epidemic in Gulu. (We had just started when a helicopter hovered into sight and then landed at Christ School’s football field! It was the ministerial delegation, a bit lost. They eventually found their way to town while we continued our training.) The doctor lectured on the basic facts of Ebola, and both he and the nurse provided a lot of confidence, a boost in morale, an appeal to get back to work. She stood up in her navy blue uniform spattered on one side with purple bleach fades, and said proudly this was her badge of having worked in the isolation unit. I liked that. But of course NHC is not an isolation site, so the focus there needs to be on normal health care. One lesson I’ve learned is that the Ministry needs to clearly state the non-Ebola guidelines at the very beginning. Staff are confused about who needs to wear what protective gear, when, how to access more, how to call for help, whether there should be labs open, etc. It is getting worked out now, but it has taken more than a week. I like the doctor who came, he’s done a number of C-sections already and seemed fairly reasonable . . . But he did give out some misinformation, and he did imply that MSF was not running the isolation unit properly but now that the Gulu nurses were here that would all be sorted out. I spoke up on that, I feel that there should NOT be any even slight spirit of one-up-man-ship, of blame, but rather respect for each person’s work and contribution. Another lesson we’ve seen is that it is much easier to tell people what to do than to actually provide what they need to do it. The staff listened to the lectures, but now they have to organize a requisition and fight for their own gloves and boots and bleach. In this kind of crisis it seems that the supplies should be pushed down from above, not held until they are clamored for from below.
Meanwhile Scott met the Minister, Dr. Mallinga. This was very confidence boosting, an upsurge on the roller coaster. Another lesson of this crisis is that there are some brilliant and dedicated doctors in this country. The Minister is one of them. Scott said he addressed the issues of witchcraft and discrimination that have arisen by saying that we are like full glasses of water, when trouble comes we are shaken and whatever is inside spills over, the trouble of life merely reveals the heart. It sounds a bit like what Jesus said to the Pharisees . . .For some that means the evil just below the surface comes out. For others that means the charity and self-sacrifice are called forth. He appealed for the latter. The government has now allocated 6 BILLION shillings to the response, which is 6 billion more than they had last week. . . . The crisis has also pointed out the problem of medical staffing. The Minister said Uganda has lost about 200 doctors to South Africa, 3 anesthesiologists to Rwanda, countless nurses to Kenya, more new grads to Sudan where NGO’s are paying huge salaries. Even here in Uganda some of the best minds and hearts we’ve seen responding to the crisis are Ugandan doctors who have left Ministry of Health to work for the WHO. This discourages me, how can the country be covered when the Ministry system is poorly paid, bureaucratic, frustrating, and easily circumvented for more lucrative jobs? Why isn’t medicine more like the military, you have to do your two years of service after school, you are posted all over the country and everyone has to put in their time? It used to be that way, and this is one instance where decentralization has probably hurt more than helped. I can already see that some of these hard working and helpful men are going to be gone in the next few weeks, and we’ll be left with the same hobbling health system we had before, minus Jonah.
It is a week today since Jonah died. Though Melen and I had a little cry together this morning, I can see some signs that she is emerging, thinking a little bit into the future beyond the 21 day contact isolation period, she even smiled once this morning at her daughter Sarah’s antics. Thanks for praying for her.

Monday, December 10, 2007

Just when I thought the tears had run dry, someone sent us a beautiful picture of Scott and Jonah together taken a few months ago. I still can’t believe he won’t come back from Kampala any day and sort things out. I do think sometimes about him meeting my Dad in Heaven. They had a good relationship of respect, and I like to think of them recognizing each other there.

OK here is today’s report. Scott was gone from morning to night. The day began with a clinical conference, with Scott, Dr. Jackson Amoni from Ministry of Health, our heros Dr. Yoti from WHO ( also a Ugandan and formerly with MOH) and chief nurse Rosa from MSF. The four of them were tasked to sort out protocols and procedures for caring for the sick in isolation. Our main contribution is to agree with Dr. Yoti and confidently endorse him to everyone else. Scott then went to Kikyo to try and install the Gray’s “village phone”, which includes an antennae we hoped would overcome the mountainous terrain and distance from the tower and allow that health center immediate phone access at all times. Sadly it did not work, but we are still grateful that the Grays let us try. Somewhere in there he managed to get the lawnmower back to complete the airstrip mowing for the daily flights, and to pick up mosquito nets for pregnant and HIV positive women, and to see some maternity patients too I think. The day ended with the two of us zipping back up to Bundibugyo on the motorcycle for the evening task force meeting, while Scott Will, who had been working at Nyahuka Health Center today, stayed back to cook us dinner. Very nice.

The meeting tonight was a bit calmer and more amicable, thanks for prayers for cooperation. Here are the facts:

Cumulative cases: 115

Cumulative deaths: 29 (CFR 25.2%)

Contacts: 368. 298 were seen today! Amazing really if you think about the challenges.

LABS AT LAST!!: 17 patients had samples run today in Entebbe, some were specimens that had been collected days ago. 10 of 12 samples from Bundibugyo were positive for Ebola, either by antigen detection or production of antibody response. ZERO of 5 samples from other districts were positive. In other words all confirmed cases to date stem directly from Bundibugyo. There is still a large back-log of tests so we are not quite ready to breathe a sigh of relief, but at least the initial news is good, the spread may not be as fast and violent as feared.

Jonah’s labs: his initial test done on Saturday (day 4 of illness, day 2 of admission) was positive for antigen (presence of the virus) but negative for IgM antibody (he was not yet mounting a detectable immune repsonse). The sample two days later was positive on both counts. It is no surprise that he truly died of Ebola, but provides some closure to have it confirmed.

Tribalism: Sadly almost all the cases stem from the Bakonjo tribe (including Jonah). The Bakonjo are a minority in the district; most of them live in Kasese and Congo. The majority tribe here, the Babwisi, have been relatively spared. Since transmission is person to person, this makes sense, that the disease would stay within one primary ethnic group. However even in ADF days there was suspicion and accusation between the tribes. Now the Bakonjo are accusing the Babwisi of poisoning them, and we heard that today some refused to buy rice in market that was grown by the Babwisi women. Yet another way that fear and misunderstanding can be used to foment ethnic unrest.

More unrest: on the Fort Portal side of the mountains, that district had decided to locate their isolation unit as close to the Bundibugyo district border as possible, in Kichwamba. But local people rioted last night, breaking windows in the ward, and forcing transfer of two suspect cases back to Fort Portal Town’s main hospital. These tensions are essentially the same that sparked Rwanda, the fear that one’s own family and tribe are at risk and therefore the justification to lash out violently against those perceived to be enemies. We are praying for peace. Thankfully no violence here where the real cases are, but the mistrust and bickering is a smaller symptom of the same issue.

More discrimination: a local government official who has been conspicuously absent all week showed up today, complaining that in Kampala he was ostracized as “the walking dead” because he was from Bundibugyo. We all acknowledge that the country is in a quandary, most people are very upset about the possibility of catching Ebola, and anyone from Bundibugyo is suspected to be a carrier. The district’s ONLY bank closed today, in spite of pleas by the security officer that there was no danger in banking. Inability to access money will definitely put a damper on the response.

Tomorrow’s tasks: The minister of health himself and three other top ministry officials will fly in for an official visit tomorrow. Before that Scott and Dr. Yoti will ceremoniously discharge Dr. Sessanga from his home isolation, declaring him cured. Then the Scotts (both) will be participating in training staff at NHC to help allay fears and provide adequate protection so patient care for non-Ebola cases can proceed.

We can’t thank you enough for your care. We’ve been particularly encouraged by several people contributing to the emergency response fund. We will be spending some immediate money on more gloves, and trust that the school fees for Jonah’s children will be provided by the time they need them in late January. It is good to sense how clearly we are only one small part of the larger community of Christ in this time.

Our Mission

who we are

paradox:
1. something that combines contradictory features or qualities.
Life in Africa is full of contradictions - the beauty and pain; the abundance and the poverty; the joy and the sorrow.
Our lives, too...dying that we might live; strong in our weakness; sinners yet saints.
2. a "pair of docs"